Clinician emotional response toward narcissistic patients: A preliminary report

Abstract

Patients with narcissistic personality disorder (NPD) are among the most difficult to treat in therapy, especially due to their strong resistance to treatment and other difficulties in establishing a therapeutic relationship characterized by intimacy, safety, and trust. In particular, therapists' emotional responses to these patients can be particularly intense and frustrating, as often reported in the clinical literature; however, they have rarely been investigated empirically. The aims of this preliminary study were 1) to examine the associations between patients' NPD and therapists' distinct countertransference patterns, and 2) to verify whether these clinicians' emotional reactions were influenced by theoretical orientation, gender, and age. A national sample of psychiatrists and clinical psychologists (N = 250) completed the Therapist Response Questionnaire (TRQ) to identify patterns of therapist emotional response, and the Shedler-Westen Assessment Procedure-200 (SWAP-200) to assess personality disorder and level of psychological functioning in patients currently in their care with whom they had worked for a minimum of eight sessions and a maximum of six months (one session per week). From the whole therapist sample, we identified a subgroup (N = 35) of patients with NPD. Results showed that NPD was positively associated with criticized/mistreated and disengaged countertransference, and negatively associated with positive therapist response. Moreover, the relationship between patients' NPD and therapists' emotional responses was not dependent on clinicians' theoretical approach (nor on their age and gender). These findings are consistent with clinical observations, as well as some empirical contributions, and have meaningful implications for clinical practice of patients suffering from this challenging pathology.